What's going on?

[roslynr]

I returned to cpap use earlier this year after stopping for about 2 years. My sleep study (at home) AHI is 65. I still suffer from insomnia and fatigue most days. I am mouth breather but can't find ffm that works for me, so use nasal mask (Resmed mirage FX). It seems that I tend to have more CAs than OAs in general. Leaks haven't been too bad but have severe aerophagia, so last two nights tried lightly taping mouth. I slept great last night but SH stats don't look so good. Wondering if any one can tell me what's going on.
Here are Sleephead pics from last night, also Encore stats for past week: http://s1289.photobucket.com/user/rozr1 ... 7575462567

Thanks for your support.

[Pugsy]

Your minimum pressure is 10 cm? Maximum...16cm?

Do you still have access to a sleep doctor? In the past was there ever any mention of centrals in any of your sleep studies?

Here is the SH graph...it's pretty ugly. Too many obstructives as well as clear airway (centrals).
You say you feel you slept great with not many wake ups last night? Is that true as not many wake ups? If so then we can't likely blame those CAs or awake breathing...so it makes them kinda worrysome.

How did they come up with the 10 to 16 range for therapy? Did you have a titration study done in a lab? If so, any mention of centrals?

[roslynr]

i'm aKaiser member so not really good support for apnea; no sleep doc, only basically trained techs. I seem to have more knowledge than they do. The doctor who reviewed home sleep study did not mention CA at all; he also did not provide titration numbers at all. The techs also din't do that so I self titrated. Reduced max pressure because of aeropahagia, but since it's still bad, think I will start raising max pressure and see how that goes.

Also good sleep last night is relative to when I don't sleep at all or only sparingly.

Do you think I should contact my primary doctor re CAs or referal to sleep doctor if Kaiser has one? I do have some atrial fibrillation and I underststand that there is some connection between the two. OOOps, just checked echocardiagram report, and do not have AF, rather just some mild diastolic dysfunction. My bad.

Thanks for your reply. If there is other data that you think might be useful, just let me know.

[Pugsy]

Reduced max pressure because of aeropahagia, but since it's still bad, think I will start raising max pressure and see how that goes.

Actually I was thinking of reducing the maximum..not raising it. If those are pressure triggered centrals (complex sleep apnea) increasing is the wrong way to go with that maximum..besides it causes aerophagia issues which just compound the problem.

From the presence of the Obstructive apneas in large numbers...the minimum is the most critical pressure and not the maximum.
Only thing is...if we are looking at complex sleep apnea here...more minimum might also make the centrals worse.
Of course there is a chance that the centrals are arousal centrals coming from little mini arousals (that you don't remember) and if so then maybe we can reduce those by reducing the obstructive apneas.

If it were me I would try increasing the minimum to 11 cm..and limiting the max to 13...I know you may hit the max but at this point that is preferable to running the chance of that increasing pressure triggering the centrals.

What is needed is to find a pressure that adequately prevents the OAs and we don't see a bunch of CAs. If we can't do that with a bit of trial experimentation then you most likely need a different type of machine.
If you do have Complex Sleep Apnea...APAP is for sure not the way to go unless in a tight range.
Now I am not saying that you have CompSA..but it is a possibility and one that we have to keep right up front.
Maybe those centrals are arousal centrals...I have seen it happen...someone increases the pressure in an effort to reduce the OAs and the centrals go away because they were arousal centrals and not compSA centrals. Worth a try.

If no success...then Kaiser does have a program available where you get more specific attention..you would need an in lab titration study for sure.

If it were me...I would try the easy way first just to see if I could decrease the OAs (a little more minimum pressure) and not have the CAs increase and hopefully decrease.
More maximum is NOT the way to go for sure.
I would start slow and low...increase the minimum to 11...reduce maximum to 13 and let's see what happens to the OAs. Try to fix one thing and hope we get lucky with the other thing that we can't fix using this type of machine.

[roslynr]

Okey dokey. Will try your suggestion tonight and report back tomorrow.

Again, I much appreciate your help.

[Pugsy]

While I am thinking about it.
This video does a good job explaining CompSA.
https://www.youtube.com/watch?v=CU-XTcf ... e=youtu.be
This may or may not be your problem but if we can't get the OAs reduced enough and the centrals to reduce...it's a very strong possibility.
Sometimes the pressures needed to prevent the obstructive stuff just triggers the centrals. Sometimes we can find a fine line with the pressure where the obstructives are well controlled and the centrals are in manageable numbers. Worth trying.
We will know real quick heading in the right direction.

I do think that you should go ahead and make whatever kind of appointment you need for follow up to get the ball rolling...just in case.
I know they can't likely get it done tomorrow..
With the Afib and the other stuff...let's not wait 2 weeks and then make the appointment.

[robysue]

First the relevant images:

Last night's sleepy head data:


and


If this night's data is typical, then clearly therapy is not yet effective.

Big problems: All those events AND the fact that CAs are making up 50% of the apneas scored are big problems.

Judging from the huge cluster of OAs between 1:00 and 1:48 and the corresponding rise in pressure, it looks like the starting pressure of 10cm is not high enough to effectively prevent most of your obstructive events. The OAs appear to become well controlled once the pressure reaches about 13.5 cm of pressure. But when the pressure is around 13.5 or higher (from 1:48 am to roughly 3:45 am), there are a huge number of CAs present. There are also a huge number of CAs present both earlier in the night and later in the night at lower pressures. The events settle down as the leak grows. But except for the short-lived spike in the middle, the long leak seems to be below where PR machines typically flag Large Leaks (and this is confirmed in the Encore data.)

The obvious question is: Is this a typical night or an outlier?

roslynr also posts the summary data for the last 8 nights from Encore:



We can see from this data that on 7 of the 8 nights, the overall AHI is clearly well above 5.0 AND that CA's make up at least 50% of the apneas on almost every night. The CAI itself appears to be above 5.0 on all but one of the eight nights. So the Sleepy Head data night is NOT an outlier. We can also see that the amount of time Encore flags as Large Leak is pretty trivial and that the worst night for events in general and CAs in particular occurs on a night when there were no Large Leaks flagged.

So this raises the question: Are those CAs real? If so, then it looks like roslynr is dealing with CompSA and finding a pressure that can prevent the OAs without triggering the CAs may be tough.

So some questions to try to tease out how many of those CAs might be "false" events vs. how many are real:

1) How restless were you during this night? Were you tossing and turning and spending a lot of time trying (unsucessfully) to get to sleep or back to sleep after a series of wakes?

2) Is the aerophagia waking you up at night? Are the aerophagia wakes very frequent? Do you spend significant time tossing and turning after you wake up with aerophagia?

3) In general how much time do you spend in bed awake with the mask on and the machine running?

4) Did your home sleep study say anything about CAs as well as OAs?

5) Has a doc looked at the machine data? If so, what did s/he have to say about the large number of CAs?

[robysue]

Do you think I should contact my primary doctor re CAs or referal to sleep doctor if Kaiser has one?

Yes, those CA numbers are pretty alarming if you think you were asleep when they're being scored.

I do have some atrial fibrillation and I underststand that there is some connection between the two.

Thanks for your reply. If there is other data that you think might be useful, just let me know.

Given the history of afib, you may also want to talk with your cardiologist about the periodic breathing that's being scored by the machine. Most of the time we can ignore PB, but there are certain types of PB that are strongly associated with various kinds of heart disease. It may be nothing to worry about, but it looks like the machine is flagging about 10%-15% of your breathing as PB on any given night and so it may be prudent to have that checked out.

[roslynr]

RobySue, here are answers to your questions:

1) How restless were you during this night? Were you tossing and turning and spending a lot of time trying (unsucessfully) to get to sleep or back to sleep after a series of wakes? Not restless at all last night. No waking at all.

2) Is the aerophagia waking you up at night? Are the aerophagia wakes very frequent? Do you spend significant time tossing and turning after you wake up with aerophagia? Normally, the aerophagia does wake me up and many times poainful in addition to annoying. Last night, no wake up.

3) In general how much time do you spend in bed awake with the mask on and the machine running? Maybe 15 to 30 minutes. If it goes beyong that I ususally get out of bed and relax on couch where I may nap on and off, without cpap.

4) Did your home sleep study say anything about CAs as well as OAs? I only received very bare study output, no mention of CAs.

5) Has a doc looked at the machine data? If so, what did s/he have to say about the large number of CAs? It ws pulmonary doc who reviewed sleep study and no mention of CAs.

[robysue]

RobySue, here are answers to your questions:

1) How restless were you during this night? Were you tossing and turning and spending a lot of time trying (unsucessfully) to get to sleep or back to sleep after a series of wakes? Not restless at all last night. No waking at all.

2) Is the aerophagia waking you up at night? Are the aerophagia wakes very frequent? Do you spend significant time tossing and turning after you wake up with aerophagia? Normally, the aerophagia does wake me up and many times poainful in addition to annoying. Last night, no wake up.

3) In general how much time do you spend in bed awake with the mask on and the machine running? Maybe 15 to 30 minutes. If it goes beyong that I ususally get out of bed and relax on couch where I may nap on and off, without cpap.

Combining the answers to 1, 2, and 3: The CAs are something we can't immediately dismiss. But as Pugsy's pointed out, there's still a good chance that they're post arousal events that would not be scored on an in-lab sleep test. Pugsy's idea of increasing the min EPAP slightly and reducing the max IPAP down as well is well worth trying. If the CAs start to abate, then we'll know they were post-arousal CAs and fixing the arousals should fix the CAs. If the CAs really are a sign of CompSA, they won't go away.

4) Did your home sleep study say anything about CAs as well as OAs? I only received very bare study output, no mention of CAs.

So we know the problem is NOT primary central sleep apnea.

5) Has a doc looked at the machine data? If so, what did s/he have to say about the large number of CAs? It ws pulmonary doc who reviewed sleep study and no mention of CAs.

Any chance the pulmonary guy would be able to review the data coming off your machine?

Also, you've mentioned that you suffer from insomnia: How frequent is it? How does the insomnia manifest itself? And what (if anything) do you do to try to address the insomnia issues?

[roslynr]

Insomnia is very frequent, mostly in form of trouble falling asleep and waking up after 2-3 hours of sleep. Had used Ambien ocassionally and slept well; primary care doctor suggested I try melatonin instead. Have been doing that for a couple of months; seemed to work for awhile but not so much anymore.

Also curious as to why you think central apneas not a problem. Sleep study was done at home with just a wrist band and oxygen level device. How would doctor know what kind of apneas I was having?

[Pugsy]

Home studies don't always differentiate between obstructive apneas and central apneas.
We don't know if your home study didn't see any centrals because there weren't any or it just didn't have a way to tell one from the other. If it only recorded cessation of breathing and oxygen level dips...then it is possible that you had the centrals all along and that's a big problem. We don't know what they used in the home study though.
It depends on the home study...some are just basic screening tests and for most people with plain jane vanilla OSA they are sufficient.

You might not have had any centrals during the home study and in that case we see them pop up with the initiation of cpap pressure but without an in lab titration we don't know why or if they are even the real deal.

CPAP machine "centrals" can sometimes be "centrals" that wouldn't be flagged during a sleep study in a sleep lab scored by a tech.
The machine has some limitations...like it doesn't know if you are awake or not and it can flag awake breathing irregularities by mistake. Happens quite often and this is why we ask about sleep quality and did a person spend a lot of time awake on the machine.
So some "centrals" are normal and not a problem. They become a problem when they occur in large numbers that we can't explain away or cause desats or impact sleep quality.

Until proven otherwise...I always tend to lean towards the cautious side when we see centrals that are in the numbers where we would worry about them. Yours qualify for worrying about them. There's no need to panic though...we do what we can that might help reduce the numbers and then decide if there's need to worry.
I have seen centrals in the number you are having pretty much totally go away once the obstructive apneas are reduced so that post arousal centrals are reduced. So it's not impossible. We can't tell from what we see from the machine data if your "centrals" are post arousal centrals or the real deal complex sleep apnea central with breathing instability brought on by cpap pressure.

What we do see that we know for sure needs work that we know how to fix would be the OAs...so try to fix what needs fixing in the normal manner and then evaluate the centrals.
If we can get the OAs down to 5 or less per hour and we still see a truckload of centrals...you need to have additional follow up for sure for the problem.
If we can get the OAs down to 5 or less and see a marked reduction in the centrals so that the numbers are no longer alarming...I won't know if you have CompSA and we got lucky and found the fine line where your OAs are well treated and CAs aren't triggered or if you just had post arousal centrals from the OAs.

Try the super easy thing to do first...see what happens. At this point things are pretty much in the toilet anyway.

[robysue]

Simply want to say: Pugsy's last post is RIGHT ON the mark. I agree with everything she's said.

Try the easy things first. We can hope that a cautious approach to increasing the min pressure combined with reducing the max pressure helps to resolve the number of OAs. And if the CAs also disapper, we know you don't need to worry about them. But if the CAs don't resolve, then we know you do need to worry about them.

I'll write more on the insomnia when I get a chance.

[roslynr]

Hi all, here's my data from last night with min/max set to 11/13. It was a bad sleep night as I couldn't fall asleep so first part of graph is mostly awake stats. I did go back to bed at about 5:30am. Though i'm still seeing high clear airway apneas looks like there may be some good news with new settings. The period after 7am seems to be relatively apnea free. I';m hopful that this will carry over when I do get a good nights sleep.
Here are the SH images: http://s1289.photobucket.com/user/rozr1 ... 4375136113

Again, thank you so much for your input. Hopefully, tomorrows numbers will be better.
I did make appt for next week with my primary care doctor just in case numbers don't improve.

Roz

[Pugsy]

Indeed the period after 7 AM does offer some hope. We just need more hours like that time frame.
Hopefully tonight you won't have such a rough night getting to sleep and we will be able to better evaluate the results.
More hours of continuous sleep is needed to have an better idea what the results might be.
The period before the 7AM...were you asleep or semi awake. We wonder if those are sleep onset/sleep stage transition centrals or simply some awake breathing irregularities.
Let's hope tonight that you are able to get straight away to sleep and stay asleep.
If for some reason you have trouble getting to sleep straight away there is something that you can do to help determine if what gets flagged is real or awake stuff...periodically if you are still awake and have the presence of mind to sort of mark the awake time by turning the machine off and on quickly it would help with the evaluation.
You don't have to leave it off..just a quick off and on again. Normally we can see the break easily enough...especially on the leak line so make sure your leak line shows on your screen shots.

You can turn off the AHI graph...it's redundant information anyway. Go to Preferences/Graphs tab and remove the check mark in the AHI graph box. That way it doesn't take up screen shot space.